What Trumpcare Means for Women

On Monday, House Republicans released their much-anticipated "repeal and replace legislation"―the bill they intend to pass to dismantle the Affordable Care Act (ACA).

The new plan not only overhauls how health care is financed for people who don't get insurance through their employers, but fundamentally changes the extent to which the government is responsible for helping people get comprehensive, affordable health care.

This legislation is not a done-deal—some Republicans already oppose it, either because they're worried about pushback from constituents who've gotten insurance through the expansion of Medicaid under Obamacare or because they feel it doesn't go far enough to repeal the landmark 2010 bill. Moderate Republican senators Susan Collins (R–ME) and Lisa Murkowski (R–AK) have already signaled they won't pass any version of the bill that defunds Planned Parenthood (which this bill does for at least one year, with no provision to re-fund). Even if the Republicans plan to ram the legislation through the Senate with a simple majority vote, they can't lose more than two votes from their own ranks and see it enacted. And we have no idea how much it costs, which is likely to be a sticking point for many Republicans in both chambers who are on the fence.

So, yes, it's fair to say this language isn't set in stone. But this is the current offering, and it's worth taking a look at what Trumpcare might mean for women.

Generally, this is not great news for women living in poverty

The plan would freeze Medicaid expansion, which was one of the main ways the ACA was able to cover millions of low-income Americans, and millions of women, after January 1, 2020.

Since the poverty rate is higher for womenthan it is for men (rates for women of color and women with disabilities are even higher), this change will most likely affect women more acutely than men. Tax credits for low-income individuals will also be reduced.

More specifically, the emphasis on Health Savings Accounts could negatively affect women in poverty

The proposed plan emphasizes Health Savings Accounts, in which participants put aside pre-tax dollars for future medical care. While HSAs are useful for those who have regular, expected medical costs (and regular, decent-paying jobs), they're impractical to use for emergency costs and for those who can't afford to save.

Undocumented women are likely to be shut out of health care

Immigrant women outnumbered immigrant men in 31 states and Washington D.C. in 2015. Under Obamacare, Medicaid programs allowed applicants a reasonable leeway period after receiving medical care to provide documentation showing they are citizens or eligible immigrants.

The House GOP plan would "close this loophole," by requiring everyone to prove their citizenship status before receiving care. This would likely keep many immigrants from seeking medical care.

Elderly women may feel more of a sting than elderly men

Before the ACA, it was common practice for insurers to jack up prices for the elderly. Currently, the ACA "limits the cost of the most generous plan for older Americans to three times the cost of the least generous plan for younger Americans." Under the new plan that limit jumps to five times more, though it gives states the options to set their own ratios. With more elderly women living in poverty than men (10.3 percent versus 7 percent), that change is likely to affect elderly women more sharply than elderly men.

The GOP plan does offer new tax credits to Americans over the age of 60, but according to David Certner, legislative policy director for the AARP, these credits are not enough to balance out new charges to the elderly: "You're both jacking up the prices and giving people less of a subsidy, which is a damaging combination," Certner told Vox.

Women who depend on Planned Parenthood to administer safe, legal abortions—or for literally anything else—may have a harder time getting that care

The GOP plan will essentially defund Planned Parenthood by eliminating the hundreds of millions of dollars it receives from the government in Medicaid reimbursements. That's approximately 75 percent of all the federal money Planned Parenthood receives, not a penny of which is allowed to be used for abortion anyway. And experts have shown that Planned Parenthoods is often the only place women can go to access consistent, dependable OB-GYN care in their neighborhoods.

Worth mentioning here and everywhere else: One in five U.S. women has visited a Planned Parenthood clinic for birth control, a cancer screening, a pap smear, STD tests, or, in some cases, pregnancy termination. Abortion accounts for three percent of the organization's services.

Even women who have private insurance and want an abortion may find it's harder (and more expensive) to get one

Emily Crockett points out at Vox that the bill could derail not only Planned Parenthood, but "the entire private insurance market for abortion coverage."

Trumpcare, cleverly, doesn't ban insurers from covering the procedure. A woman can purchase separate abortion coverage or a "rider" on her health care plan to fund one. But "it doesn't allow that coverage to be subsidized in any way by the government," Crockett writes, meaning that any tax credits for which a woman is eligible can't be applied to plans that cover abortion except in the cases of rape, incest, or when the procedure is needed to save her life.

All of this is to say, insurance companies have little incentive to cover abortion, knowing that consumers are unlikely to opt for plans that are more expensive for the sake of including an abortion provision. "It puts abortion outside mainstream medical care," Donna Crane, vice president of policy at NARAL Pro-Choice America, told us. "And that's discriminatory and humiliating."

Women in abusive or otherwise troubled marriages will have to file jointly for tax credits

Under the GOP plan, if a taxpayer is married, "no credit shall be allowed under this section to such taxpayer unless such taxpayer and the taxpayer's spouse file a joint return for such taxable year." This may sound minor, but according to Gretchen Borchelt, vice president for reproductive rights and health at the National Women's Law Center (NWLC), wording like this puts many women at risk.

"We are very concerned about that requirement, because it really ignores a host of situations like domestic abuse, a pending divorce, an incarcerated spouse, where filing a joint return may not be possible or safe," Borchelt told ELLE.com. Filing joint taxes with an abusive spouse who refuses to grant a divorce means the spouse would have access to sensitive personal information.

Borchelt says the NWLC worked with the Obama administration to address this issue in order to keep women safe. "Now this plan is just going to start over and reimpose a requirement like this, and have no idea what it could look like down the road."

Women who received maternity care under the ACA's essential health benefits rule many no longer have it covered

Thanks to the ACA, insurers had to stop making women pay more for plans that covered maternity care as well as a host of "essential health benefits" that included mental health services and addiction treatment. The new plan intends for those protections (as well as Medicaid expansion) to be "sunsetted" by 2020, leaving it up to states to decide whether insurers must cover those services; how much a woman has to pay to access essential health services will vary tremendously depending on her zip code. In some states, it'll mean she has to pay potentially thousands of dollars more to deliver her baby.

According to the National Women's Law Center, in states that didn't mandate maternity coverage, just six percent of individual market plans included maternity benefits before Obamacare insisted coverage was a required health benefit. Experts estimated that the cost of even an uncomplicated hospital delivery set women back over $10,000. If women opted or needed to have cesareans, the figure climbed to almost $18,000.

"We lose that guarantee for women [that they'll have maternity coverage]," says Crane. "In all likelihood, the market will go back to how it was before we had the ACA." Crane adds that it's "especially ironic that members of Congress who like to declare themselves pro-life have decided to gut the maternity care benefit."

Women who depend on their health insurance to fund mental health treatment or substance abuse services may have to pay out of pocket

Since the new legislation will both phase out Medicaid expansion and eliminate the essential health care benefits that have helped people gain access to mental health care, treatment for everything from depression to opioid addiction could become an out-of-pocket expense for millions of Americans.

Less than 24 hours after the plan's release, four GOP senators—Shelley Moore Capito (R–WV), Cory Gardner (R–CO), Rob Portman (R–OH), and Lisa Murkowski (R–AK)—wrote in a letter to Senate leadership that this point, especially, concerned them. Given that a third of people on Medicaid have a mental health or substance abuse disorder, making it the "largest payer of mental health and substance use services in the United States, it is critical that any healthcare replacement provide states with a stable transition period," they wrote.

"We believe Medicaid needs to be reformed," they concluded, "but reform should not come at the cost of disruption in access to healthcare for our country's most vulnerable and sickest individuals."

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